The Athlete's ECG: Sport-Specific Patterns, Physiological Remodeling, and Clinical Interpretation (JACC: Advances September 2026)-Article: The Athlete's ECG: Sport-Specific Patterns, Physiological Remodeling, and Clinical Interpretation

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This review explains how intensive training shapes the athlete’s ECG and why interpretation must be sport-specific. Regular exercise causes “athlete’s heart,” a set of structural, functional, and electrical adaptations influenced by training type, sex, age, and ethnicity. Endurance sports mainly produce volume overload and typically show sinus bradycardia, first-degree AV block, early repolarization, incomplete right bundle branch block, and high QRS voltages. Strength sports create pressure overload and are more associated with increased QRS voltage, higher resting heart rates, and concentric remodeling. Mixed sports, such as soccer and basketball, show intermediate or overlapping patterns.<br /><br />Most ECG findings in athletes are benign and reflect physiological adaptation, but some patterns require further workup. In particular, lateral, inferolateral, or anterolateral T-wave inversion is considered abnormal and may signal cardiomyopathy. Anterior T-wave inversion can be normal in some athletes if it is preceded by J-point elevation and limited to V1-V4, especially in asymptomatic male athletes without concerning family history. Profound bradycardia, marked QTc prolongation, low QRS voltages, or arrhythmias with suspicious morphology also warrant evaluation.<br /><br />The authors emphasize that correct ECG interpretation depends on integrating athlete-specific ECG criteria with clinical context, training history, and imaging when needed. Echocardiography and cardiac MRI are useful when findings are ambiguous or abnormal. The review also discusses how sex and ethnicity affect ECG patterns, with Black athletes and female athletes showing some distinct repolarization and voltage features.<br /><br />The paper concludes that modern athlete ECG screening can improve detection of occult disease while reducing false positives, but only when interpreted by clinicians familiar with sport-specific patterns and contemporary guidelines.

Meta Tag

Concept Athletic ECG

Concept Physiologic Remodeling

Concept T-wave Inversion

Concept Athlete-Specific ECG Interpretation Criteria

Concept Sinus Bradycardia

Keywords

athlete ECG

sport-specific interpretation

athlete's heart

sinus bradycardia

T-wave inversion

endurance sports

strength sports

ECG screening

cardiomyopathy

echocardiography

Athletic ECG

Physiologic Remodeling

T-wave Inversion

Athlete-Specific ECG Interpretation Criteria

Sinus Bradycardia